Near-Term Inductions And Newborn Mortality
06.02.11: When you’re close, but not close enough to your due date
Melanie had a pretty good idea when she got pregnant. She knew roughly when she’d had her last period and more or less when she and her boyfriend “did it.” That’s how her doctor determined her due date – the 40-week mark when her baby would be more or less expected to deliver on his own (give or take a week or so). She had a normal pregnancy without any pesky health issues other than a persistently achy ligament across her pubic bone and groin. Her doctor diagnosed this as round ligament (the one that attaches to her ever-growing uterus) pain, told her to take Tylenol and take it easy.
A few weeks before her due date, Melanie complained to her doctor again that the ligament pain was driving her crazy. She had a hard time walking, moving in bed or even standing for more than a few minutes. Like every woman in her last month of pregnancy, Melanie was crazy-uncomfortable, super grumpy and sooo ready to be done. Her doctor took pity on her and scheduled an induction for the day she turned 38 weeks pregnant. He said that was close enough to her due date that everything would be fine. And it probably would have been fine if Melanie’s baby’s had actually been 38 gestational weeks on his birthday.
The induction went smoothly but when Melanie’s baby was born, he struggled for air and appeared to be much closer to 36 weeks gestation. He wound up in the NICU with respiratory and blood sugar problems. Melanie’s son was born prematurely. Her more or less rough estimate of when she’d had her last period and when she’d gotten pregnant were off by a very important couple of weeks. Her doctor may have had his heart in the right place, but he took a dangerous shortcut that cost Melanie’s son a full month of prenatal development he desperately needed. Melanie’s been kicking herself about going with that induction instead of waiting for labor to start naturally. “What the heck was I whining about? My son spent a week in the NICU getting tons of shots because I thought I had too many aches and pains.” Melanie’s son is fine now, but Melanie has a ways to go before she’ll really feel OK about what happened.
New research by the National Institutes of Health, the Food and Drug Administration and the March of Dimes was published in the journal Obstetrics and Gynecology. It analyzed data about more than 46 million infants born in the United States from 1995 to 2006 and discovered that during that time, the proportion of infants born before 39 weeks of gestation increased from one in five births to nearly one in three births. They looked closely at what is called “early term or near term” deliveries (babies born between 37 and 39 weeks gestation) and found that early-term births are associated with higher neonatal, post-neonatal, and infant mortality rates compared with full-term (40 weeks gestation) births. It’s no coincidence that this was the “induction decade.” The study’s authors believe this data bolsters common sense advice: If a pregnancy is uncomplicated, that baby shouldn’t be delivered before 39 weeks.
I would argue that if the pregnancy is uncomplicated, maybe even 39 weeks is too soon. Full term is 40 weeks. Most pregnancies remain uncomplicated for another week or even two. Why not wait for spontaneous labor? If there are compelling reasons (like mom or baby are having real health problems), to jumpstart labor, then by all means do it. That’s what induction is for. Otherwise, leave it alone.
Why did we get so induction crazy? During the 90’s we saw a real spike. What used to be considered an occasional and only-when-medically-indicated procedure, inductions became as common as pedicures. Doctor’s loved the convenience factor as much as busy parents. They loved the illusion of safety and predictability that inductions provided. They loved the control. That is until the data poured in that inductions were a major player in poor newborn health outcomes and dramatically increased c-section rates. It turns out Mother Nature is usually better at Saving The Date for a baby’s birthday than anyone else. She doesn’t take kindly to having her calendar messed with.
What’s going on during those last few weeks of pregnancy? Lung development, muscle growth, fat storage, neurological finish work and a whole lot more than we know about. When a baby is short-changed these last pieces of important detail work, the result is a baby who needs more intensive care. As the study above mentions, the damage may extend beyond the NICU and well into the child’s first year. I wouldn’t be at all surprised if somewhere down the road, we discover even longer lasting effects.
I’m optimistic the tide has turned on over-the-top inductions. It seems like the word is out that unless there’s a really good reason, doctors and mothers should wait for labor to start in its’ own good time. There are still some folks, however, who say, “Eh, we’re close enough to the due date. Let’s get this party started.” As Melanie found out close enough isn’t always good enough when you’re planning a birthday party.
What should miserable women like Melanie do during those last crazy-uncomfortable weeks? If there’s really nothing wrong (aches and pains are, unfortunately, entirely normal), they should chill. Wait, rest, relax and prepare. Take your time with the last weeks of pregnancy, but don’t take it from your baby. He needs the benefits of those last precious weeks inside you to last the rest of his life.
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